The alarm has gone off in the CDU toilet. Inside the toilet was an 87 year old man in only his hospital issue paper y-fronts demanding someone call the police because he is being “held against his will”. He is refusing to leave the toilet, refusing to let you switch off the godawful crash alarm. One nurse is hanging for dear life on the other side of the door to keep it open. 2 other patients with dementia in the same bay keep on wandering past, wanting to “help”.
What is your approach to the agitated patient?
There are 2 arms to any case such as this, first off we have to ensure the safety of the patient, other patients in the vicinity, other staff, and ourselves. The next thing we need to establish is why has this person become agitated?
Medical causes of potential agitation are wide and varied. Delirium in itself should be thought of as a medical emergency, as it carries a potentially high mortality (though estimates vary hugely 20%-70%).
This mnemonic may help – “SHED WIMP HELPS”
Substances, Hypoxia, Events (vascular), Dehydration, Withdrawl, Infection, Myocardial Infarction, Psychiatric, Head Injury , Endocrine, Low BM, Pain, Seizures.
The key information here is going to be what you glean from the ambulance record, and whoever normally looks after your patient. Is their behaviour normal for them? Is it out of character? If you are seeing that patient for the first time in the ED you are in the best position to assess them, as very often family members, carers, and other information will be lost prior to the RMO’s clerking them on the medical ward 6 or 7 hour later (on a good day). If they are more confused than normal this does need investigating.
So say we’ve established that the patient has dementia, that they are in CDU for some form of social care assessment, and that to all intense and purposes there is no medical problem.
The best way to nurse someone with delirium or dementia is to keep them in a brightly lit room, with visual cues as to where they are, and what time it is. It’s important to have consistent contact with the same individuals, such as carers from a nursing home, or the same nurse. It’s important that the environment is calm, quiet, and free of interruptions. Try to make sure that the patient has access to their hearing aids, and glasses, to avoid sensory disturbances. There should be easy access to food and drink. If you were going to design an environment to provoke a patient with dementia into confusion and agitation you’d design a place pretty much like an emergency department.
It’s noisy, there is no consistency of staff, patients are moved often, there are often absolutely no visual cues as to what time of day or night it is, if there are clocks they are always wrong. The trolleys or wheelchairs are not comfortable, there is often no access to food or drink.
If they’ve trapped themselves in the toilet, or a running around the ward trying to escape you might feel under pressure to try some medication. For elderly patients with dementia most of the literature tends to recommend either haloperidol or midazolam, but there is very little good quality data for elderly patients. There is a Cochrane review of both antipsychotics and benzodiazepines in depression, they conclude that there is no difference in efficacy between atypical and typical antipsychotics, but no evidence that benzos help with non-alcohol related delirium. So be cautious with both, haloperidol is thought to be safer because it doesn’t cause as much respiratory depression. IV doses are safer and more predictable if you can get a line in.
IF you can’t get a line in, this is what I’d put in my dart gun, either of…
|Haloperidol||1-5mg IM||Avoid if QTc is prolonged (risk of Torsade)Risk of dystonic reaction|
|Midazolam||2.5mg IM||Risk of respiratory depression|
After some time using de-escalation techniques, offers of food, drink, escape, to downright begging, we tried some IM medication. I got punched in the face giving our gentleman 2.5mg of IM haloperidol. About 5 minutes later his daughter arrived. She took one look at her dad held out her hand, sighed, said “come over here Dad”, her father immediately let himself out of the toilet, and came to his daughter’s outstretched hand.
As she walked him back to his bed I heard him say “Thank god you came, I don’t know why they were keeping my trapped in that loo”
I love my job.